RadioGraphics 2010; 30:23-31
Bettina Siewert, MD , Jonathan B. Kruskal, MD, PhD , Ronald Eisenberg, MD , Ferris Hall, MD , Jacob Sosna, MD
As computed tomographic (CT) colonography is being used increas¬ingly in clinical practice, an effective quality improvement process must be ensured. The quality improvement process is outlined for the read¬er by using an adverse event during CT colonography as an example. Components of this process are the approach to a sentinel event, performance of a root cause analysis, and development of strategies for minimizing errors after a serious adverse event. Important factors include indications and contraindications for the examination, proper imaging technique, training of personnel, complications of the proce¬dure, and legal implications. Complications from CT colonography are rare. Attention must be paid to the correct technique for colonic insufflation, particularly in older patients and those who are symptom¬atic. Root cause analysis provides valuable tools for identification and implementation of improvements designed to avoid similar and other adverse events and to minimize damage.